Individual and community health is adversely impacted by disparities in health outcomes for disadvantaged and vulnerable populations. Understanding the underlying causes of health disparities is an essential step in developing interventions designed to ameliorate them and subsequently improve overall community health. This study will examine multiple social determinates that can cause disparities including: deprived neighborhood conditions, inefficient social networks, low socioeconomic status, the presence of hazardous materials in or near a neighborhood, and the lack of access to primary care services with the goal of developing novel and innovated approached to improving community health. First, our collaborative team will look for associations between these social determinants and rates of hospitalizations, emergency department (ED) use, and ED use for primary care treatable or preventable conditions. Second, geospatial models will be developed using both hospital and community level data that will identify local areas where interventions to improve disparities would have the greatest impact. Third, the associations between social determinants and health outcomes as well as the geospatial models will be validated using community surveys and qualitative methods. Fourth, our community's rapidly growing and underserved Hispanic immigrant population will be the target of an intervention informed by the research process and designed, deployed, and evaluated using the geospatial tools and qualitative research findings. The purpose of this intervention will be to reduce health disparities by improving access to and utilization of primary care and preventative services. This project will occur within a primary care practice-based research network using key principles of community-based participatory research. An advisory board of community members, key stakeholders, primary care providers, and research team members will guide the process to assure that all findings are relevant and applicable to the targeted community. All findings will be disseminated through partnering organizations within the research network and will be made available for all community members to assist in the procurement of additional resources and to broaden the scope of the intervention to include all community members that suffer from health disparities. PUBLIC HEALTH RELEVANCE: This project is designed to ameliorate health disparities by examining the underlying social determinants that can negatively impact the health of underserved and disadvantaged community members - particularly the Hispanic immigrant population. This will be accomplished by using community-based participatory research methods to leverage hospital and community level data to identify at-risk community members who would benefit from enhanced social networks with the aim of helping them to obtain resources and access primary care services. The results of this study will demonstrate the importance of several novel approaches to ameliorating health disparities including the use of community-based participatory research, the effectiveness of interventions that target social networks, and the importance of primary care access in ameliorating health disparities.